Self- disclosure of HIV sero-status to sexual partner in Nigeria

Dr. Daniel O.J. MBBS (Ilorin), MPH (Lagos), FWACP. -Lecturer 1,
*Dr. Oladapo O.T MBBS (Ilorin), FWACS- Lecturer 1.
Department of Community Medicine and Primary Care, *Obstetrics & Gynecology, Olabisi Onabanjo University Teaching Hospital Sagamu, Ogun State Nigeria.

Key words: HIV, Sero-status, and disclosure, Sagamu, Nigeria

Abstract
Objective: To assess the factors associated with self-disclosure of HIV status to main sexual partner among people living with HIV/AIDS in Sagamu, Nigeria.
Methods: A cross-sectional study of 65 HIV positive patients recruited over three months, attending the Centre for Special Studies Specialist Clinic located at the Olabisi Onabanjo Teaching Hospital Sagamu, Ogun State Nigeria. An interviewer-administered questionnaire was used to collect relevant data. Standard statistical methods and the use of Epi-Info 6.04 analyzed data.
Results: There were 26 males and 39 females with a male: female ratio of 1:1.5. The mean age of males was 43.9±11.2 years while the mean age of female was 33.7±7.5 years. This was statistically significant (p = 0.02). The mean CD4 cell count was 243.9. Heterosexual route was identified as the major route of acquisition of HIV 62 (96.9%), while 3 (3.1%) was through blood transfusion. The majority of the respondents were currently married 46 (70.8%), Christian 49 (75.4%) and had secondary school education 39 (60%). Forty-four (67.8%) of the respondents had disclosed their HIV status to their main partner. Significant factors associated with disclosure were older age, on HAART treatment, attendance of support group meeting and awareness of partners HIV status. The other factors examined but not significantly associated included currently married, time since diagnosis, and condom use. The main reasons for non disclosure were fear of separation/divorce, fear of spread of information and not wanting to bother the spouse. The most common reactions for those who disclosed were separation/divorce, being blamed for it; partner took it in good faith and domestic violence.
Conclusion: Self-disclosure rate to main partner was 67.8%. Significant factors associated with disclosure were older age, on HAART treatment, attendance of support group meeting and awareness of partners HIV status. HIV prevention programmes need to bear these modifiable factors in mind so as to further improve disclosure and reduce HIV transmission in our community.

Introduction
The HIV epidemic remains one of the greatest challenges to medicine. The high level of new infections and subsequent mortality calls for concern. With the introduction of highly active anti-retroviral treatment in developed countries, there have been a profound improvement in the quality of life and subsequent reduction in mortality of HIV patients1. The story is quite different in sub-Saharan Africa where access to HAART is still limited. Therefore primary prevention remains the most effective method of controlling the infection. HIV sero-status disclosure is important in preventing sexual transmission among sexual partners2. The knowledge of a sex partner being HIV infected may help individuals to make informed decision regarding sexual behavior. Also disclosure of sero-status can provide HIV infected individuals with the necessary social and emotional support from members of their families and the community at

large3. Earlier studies on HIV sero-status disclosure was conducted among homosexuals and later among heterosexuals in developed countries4-6. This study aims to assess the factors associated with self-disclosure of HIV status to main sexual partner among people living with HIV/AIDS in Sagamu, Nigeria.

Materials and methods
The study is a cross-sectional survey among HIV positive patients attending the Centre for Special Studies (CSS) specialist clinic located at Olabisi Onabanjo Teaching Hospital Sagamu, Ogun State Nigeria. All HIV positive patients who consented to participate in the study, which took place over a period of three months, were enrolled. Information was collected with the aid of a pre-tested interviewer-administered questionnaire by trained personnel.

Data analysis
Data was analyzed using standard statistical procedures including the use of Epi 6 statistical soft ware. We used X2 test to evaluate differences in categorical variables. Fisher’s exact test was used when cell size were less than 5. The Student’s t-test was used to compare continuous variables. Differences between data were considered significant where P < 0.05 or Odds Ratio (O.R) did not embrace unity.

Results:
A total of 65 HIV positive patients attending the CSS clinic were enrolled into the study. There were 26 men and 39 women. The male: female ratio was 1:1.5. The patients were aged between 17-61 years. The mean age of males was 43.9±11.2 years while the mean age of female was 33.7±7.5 years. The mean age of men and women was statistically significant (p = 0.02). The mean CD4 cell count was 243.9. The time between HIV diagnosis and the commencement of the study ranged from 2 weeks to 60 months, with a median of 15 months. Heterosexual route was identified as the major route of acquisition of HIV 62 (96.9%), while 3 (3.1%) was through blood transfusion. There was no history of men who have sex with men or intravenous drug use. The majority of the respondents were currently married 46 (70.8%),
Christian 49 (75.4%), from Yoruba ethic group 56 (86.2%) and had secondary school education 39 (60%). (Table I).

Forty-four (67.8%) of the respondents had disclosed their HIV status to their main partner while 21(32.2 %) had not. As shown in Table 2, bivariate analyses shows that the following factors were significantly associated with disclosure to partner at P< 0.05 significance level: older age, on HAART treatment, attendance of support group meeting and awareness of HIV status of main sexual partner. The other factors examined but not significantly associated included currently married, time since diagnosis, and condom use (Table 2).Of those respondents who are aware of the HIV status of their partners 19 (57.6%) were HIV sero-positive while 14 (42.4%) were HIV negative.

Among the 21 individuals who had not disclosed their HIV status to their main sexual partner, the main reasons for non disclosure were fear of separation/divorce (n= 12), fear of spread of information (n =6) and not wanting to bother the spouse (n=3).The most common reactions for the 44 individuals who disclosed were separation/divorce (n=12), being blamed (n=4), partner took it in good faith (n=24) and domestic violence (n=4)

Discussion
The rate of self disclosure to main sexual partner in this study was 68% with about a third of the study population yet to disclose their HIV sero-status to their main partners. Though it may appear high it is lower than the 74 -91% reported among heterosexual population in developed countries7,8. This disparity may be related to the social, economic and cultural difference between developed and developing countries.

It was observed that clients who were attending support group meeting were more likely to disclose status than those not attending support groups. This is consistent with a study that underscore the importance of social support groups in helping clients work through the psychological issues and coping strategies surrounding disclosure9. Higher levels of social support have been associated with increased feeling of well-being, improved health outcomes, and less depression and predisposition to high risk sexual practices10.

The study also showed that those who disclosed their status were significantly older than those who did not disclose their status. Younger individuals are more likely not to disclose their HIV status and they have been shown to engage in risky sexual behaviour post HIV diagnosis11. This will further increase the transmission of infection in the community if preventive measures are not undertaken. Further education and counselling should be targeted to those young individuals to reduce unprotected sexual relationship. It has also been observed that younger individuals are less likely to disclose due to lack of social support and subsequent seclusion, which might be reflected in the low level of, reported sexual relationship post-HIV diagnosis7.

Respondents on highly active antiretroviral treatment (HAART) were more likely to disclose their status compared with those not on anti-retroviral medications. HIV infected patients on HAART at this centre are receiving the drug free from the Centre for Special Studies New York12. The improved quality of life experienced by these patients as a result of the anti-retroviral (ARV) medications may make them more likely to disclose their status to their partners with a view that such partner will also benefit from the free medications. This is contrary to an earlier report which

suggest that with better therapies for HIV infection and subsequent improved quality of life, HIV infected patients are better able to conceal their illness and remain sexually active without disclosure to their sexual partners7. Moreover, it was observed in a recent study that individuals on HAART were less likely to use condoms perhaps as a result of improved quality of life and less concern for safer sex practices13. This calls for targeted behavioural interventions to prevent HIV transmission will need to be intensified among this group of individuals.

Although we have limited data on the continued sexual activity of HIV infected individuals who had not disclosed their status and are not practising safer sex. This group of individuals constitute a public health risk group for the continued transmission of the infection especially in a developing country like Nigeria where there are no laws or policies as regards partner notification and sexual contact without disclosure. In some developed countries there are statutes making sexual contact without disclosure a criminal offence14. Non-disclosure of HIV status has been condemned as both a moral and legal offence subject to both civil liability and criminal prosecution by the United States Public Health Service guidelines15. The promulgation and implementation of such laws in Nigeria may promote some form of sexual responsibilities and safer sex among HIV positive persons especially for women who are powerless in negotiating safer sexual relationship in sero-discordant relationships.

This study was cross-sectional in nature and the ability to clearly distinguish the time sequence of events leading to disclosure of HIV positive status is limited. It is difficult to assess whether some of the risk factors considered in this study such as attendance of support group, being on HAART treatment and awareness of partner’s status came before or after disclosure of HIV status. Also as a result of the small sample size, we could not use multiple logistic regressions to predict factors associated with non disclosure. Nevertheless, our study shows that these identified variables are significantly associated with disclosure. HIV prevention programmes need to bear these modifiable factors in mind so as to further improve disclosure and reduce HIV transmission in our community.

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Correspondence/Request for reprints: Dr. Daniel, O.J, Dept of Community Medicine & Primary Care, Olabisi Onabanjo University Teaching Hospital; Sagamu. Ogun State, Nigeria.
E-mail: sojidaniel@yahoo.com. +234-8033774418

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